Care coordination needs for deprescribing benzodiazepines and benzodiazepine receptor agonists.

Deprescribing of medications such as benzodiazepines and benzodiazepine receptor agonists (z-drugs) can be a complex process that varies across practices, specialties, and health care systems. Care coordination among healthcare providers, patients, families, and other healthcare system components is critical to achieving high levels of deprescribing and person-centered care. We present a framework for promoting care coordination in the context of benzodiazepine/z-drug deprescribing. Future efforts are needed to study the impact of better care coordination on benzodiazepines/z-drug discontinuation and other outcomes that are important to stakeholders

Mobile Health Technology Use in Vulnerable Populations

Given the potential for mobile health technologies (mHealth) to reduce access barriers, there has been increased interest in understanding mHealth use among vulnerable populations. Vulnerable populations are at risk of lower mHealth use, and gaps in access to and use of mHealth between vulnerable and more affluent, more educated, and younger populations could exacerbate health disparities. Using a mixed methods approach, we analyzed survey and focus group data from a study sponsored by a foundation of a large health insurer on mHealth use in vulnerable populations. A sample of low-income adults (n=345) was recruited by local social services organizations in Miami, FL, Louisville, KY, South Bronx, NY. In the first study, we assessed sociodemographic correlates of mHealth use with multivariable logistic regression analyses. In the second study, we estimated direct and indirect effects of sociodemographic characteristics on mHealth use with structural equation modeling and examined the role of digital health literacy in this relationship. In the third study, we conducted a qualitative analysis of focus group interviews with older adults to contextualize mHealth acceptance and adoption. Factor analysis identified two composite outcome variables to represent mHealth use: those activities related to searching for information and those involving greater engagement with technology for health, such as downloading and using a health app. Lower age was associated with higher search-related mHealth use. Education influenced search-related mHealth use indirectly through digital health literacy. Age and education had indirect effects on engagement-related mHealth use through digital health literacy and search-related mHealth use. Qualitative findings revealed many older adults had minimal experience with mHealth and mHealth acceptance and adoption were influenced by perception of the usefulness of mHealth, the complexity of using mHealth, and facilitating conditions such as cost and technical assistance. These findings can inform interventions used to encourage greater mHealth use in vulnerable and older populations

Comparison of Health Status and Health Care Services Utilization between Migrants and Natives of the Same Ethnic Origin—The Case of Hong Kong

Based on the 2009 Thematic Household Survey in Hong Kong, this study compared health status and utilization of health care services in Hong Kong between migrants from Mainland China and natives. Overall, Mainland migrants reported lower socioeconomic conditions, worse health status, and less health care services utilization than the natives. After controlling for socio-demographic factors, we found that the migrants were 1.2 times more likely to report fair or poor health and 0.78 times less likely to report having a usual source of care, compared with the natives. Mainland migrants also had fewer physician visits and relied more on the public sector. Within the migrant group, those who had language advantage had more visits, and the recent arrivals who stayed in Hong Kong for three years or less had fewer visits and were far less likely to have a usual source of care. The findings underscore migration as an important social determinant of health in Hong Kong. A combination of targeted social and health policies is needed to help Mainland migrants better integrate into society and to improve their access to care. Programs should be tailored to address varying needs from different subgroups among migrants

Staying Afloat Amidst the Tempest: External Pressures Facing Private Child and Family Serving Agencies and Managerial Strategies Employed to Address Them

Private child and family serving agencies operate within a turbulent environment characterized by changing client needs, interorganizational competition, resource scarcity, and demand for accountability. Qualitative data regarding external pressures experienced by private agencies across six states, and managerial strategies to address them, were collected from a 2016 electronic survey of senior agency administrators (n = 182). Specific themes were organized into the following categories: funding; operations and practice-related issues; staff recruitment and retention; laws, regulations and licensure; contracts and contractual expectations; and, interorganizational relationships. Implications for management practice and research regarding how private human service organizations navigate different external pressures are discussed

Primary care team- and clinic level factors affecting HPV vaccine uptake.

ObjectiveThis study examined patient-, care team- and clinic-level factors associated with human papillomavirus (HPV) vaccine initiation and completion.MethodsHPV vaccine initiation and completion rates among adolescents aged 9-18years were assessed using administrative data (n=38,277) from a large federally qualified health center serving predominantly Latino patients. Four clinics with particularly high and low adolescent HPV vaccine uptake were selected for in-depth case study analyses. Semi-structured interviews with clinic leaders, providers, and support staff in these clinics (n=36) examined multilevel factors perceived as affecting vaccine initiation and completion.ResultsOn average, less than half (45%) of patients had initiated the HPV vaccine; of these, 52% of patients completed all recommended doses. Vaccine uptake varied significantly across clinics but was higher among patients seen by providers specializing in pediatrics. Qualitative findings confirmed the importance of provider communication strategies but indicated that other health care team structures and processes also play an important role in vaccine uptake. Care team members in higher performing clinics were more likely to describe vaccination as a team effort rather than solely the provider's responsibility. Support staff in higher performing clinics also spent more time reviewing patient preventive care needs and preparing patients for the provider encounter. Clinic-level factors such as performance management systems and the use of immunization champions were described as important for developing an organizational climate supportive of vaccination. Tracking and reminder systems were described as important but insufficient for ensuring vaccine uptake in the absence of other supports.ConclusionsEfforts to improve HPV initiation and completion could benefit from additional attention to factors at the health care team and clinic levels. Interventions that target factors at multiple levels of influence are most likely to achieve higher vaccination rates. Quality monitoring programs may influence clinic investment in improving vaccination rates

Primary care team- and clinic level factors affecting HPV vaccine uptake.

ObjectiveThis study examined patient-, care team- and clinic-level factors associated with human papillomavirus (HPV) vaccine initiation and completion.MethodsHPV vaccine initiation and completion rates among adolescents aged 9-18years were assessed using administrative data (n=38,277) from a large federally qualified health center serving predominantly Latino patients. Four clinics with particularly high and low adolescent HPV vaccine uptake were selected for in-depth case study analyses. Semi-structured interviews with clinic leaders, providers, and support staff in these clinics (n=36) examined multilevel factors perceived as affecting vaccine initiation and completion.ResultsOn average, less than half (45%) of patients had initiated the HPV vaccine; of these, 52% of patients completed all recommended doses. Vaccine uptake varied significantly across clinics but was higher among patients seen by providers specializing in pediatrics. Qualitative findings confirmed the importance of provider communication strategies but indicated that other health care team structures and processes also play an important role in vaccine uptake. Care team members in higher performing clinics were more likely to describe vaccination as a team effort rather than solely the provider's responsibility. Support staff in higher performing clinics also spent more time reviewing patient preventive care needs and preparing patients for the provider encounter. Clinic-level factors such as performance management systems and the use of immunization champions were described as important for developing an organizational climate supportive of vaccination. Tracking and reminder systems were described as important but insufficient for ensuring vaccine uptake in the absence of other supports.ConclusionsEfforts to improve HPV initiation and completion could benefit from additional attention to factors at the health care team and clinic levels. Interventions that target factors at multiple levels of influence are most likely to achieve higher vaccination rates. Quality monitoring programs may influence clinic investment in improving vaccination rates

Endoscopic therapies for patients with obesity: a systematic review and meta-analysis.

BACKGROUND: Obesity is a major threat to public health and traditional bariatric surgery continues to have low utilization. Endoscopic treatments for obesity have emerged that offer less risk, but questions remain regarding efficacy, durability, and safety. We compared the efficacy of endoscopic bariatric procedures as compared to other existing treatments. METHODS: A literature search of Embase, Cochrane Central, and Pubmed was conducted from January 1, 2014 to December 7, 2021, including endoscopic bariatric therapies that were FDA or CE approved at the time of search to non-endoscopic treatments. Thirty-seven studies involving 15,639 patients were included. Primary outcomes included % total body weight loss (%TBWL), % excess body weight loss (%EBWL), and adverse events. Secondary outcomes included quality of life data and differences in hemoglobin A1C levels. Strength of clinical trial and observational data were graded according to the Cochrane methods. RESULTS: Intragastric balloons achieved greater %TBWL with a range of 7.6-14.1% compared to 3.3-6.7% with lifestyle modification at 6 months, and 7.5-14.0% compared to 3.1-7.9%, respectively, at 12 months. When endoscopic sleeve gastroplasty (ESG) was compared to laparoscopic sleeve gastrectomy (LSG), ESG had less %TBWL at 4.7-14.4% compared to 18.8-26.5% after LSG at 6 months, and 4.5-18.6% as compared to 28.4-29.3%, respectively, at 12 months. For the AspireAssist, there was greater %TBWL with aspiration therapy compared to lifestyle modification at 12 months, 12.1-18.3% TBWL versus 3.5-5.9% TBWL, respectively. All endoscopic interventions had higher adverse events rates compared to lifestyle modification. CONCLUSION: This review is the first to evaluate various endoscopic bariatric therapies using only RCTs and observational studies for evaluation of weight loss compared with conservative management, lifestyle modification, and bariatric surgery. Endoscopic therapies result in greater weight loss compared to lifestyle modification, but not as much as bariatric surgery. Endoscopic therapies may be beneficial as an alternative to bariatric surgery

Challenges with Implementing a Patient-Centered Medical Home Model for Women Veterans

BackgroundThe Veterans Health Administration (VA) Patient Aligned Care Team (PACT) initiative aims to ensure that all patients receive care consistent with medical home principles. Women veterans' unique care needs and minority status within the VA pose challenges to delivery of equitable, comprehensive primary care for this population. Currently, little is known about whether and/or how PACT should be tailored to better meet women veterans' needs.MethodsIn 2014, we conducted semistructured interviews with 73 primary care providers and staff to examine facilitators and barriers encountered in providing PACT-principled care to women veterans. Respondents were located in eight VA medical centers in eight different states across the United States.ResultsRespondents perceived PACT as improving continuity of care for patients and as increasing ability of nursing staff to practice at the top of their license. However, the implementation of core medical home features and team huddles was inconsistent and varied both within and across medical centers. Short staffing, inclusion of part-time providers on teams, balancing performance requirements for continuity and same-day access, and space constraints were identified as ongoing barriers to PACT implementation. Challenges unique to care of women veterans included a higher prevalence of psychosocial needs, the need for specialized training of primary care personnel, and short staffing owing to additional sharing of primary care support staff with specialist providers.ConclusionProviders and staff face unique challenges in delivering comprehensive primary care to women veterans that may require special policy, practice, and management action if benefits of PACT are to be fully realized for this population

Patient and researcher stakeholder preferences for use of electronic health record data: a qualitative study to guide the design and development of a platform to honor patient preferences.

ObjectiveThis qualitative study aimed to understand patient and researcher perspectives regarding consent and data-sharing preferences for research and a patient-centered system to manage consent and data-sharing preferences.Materials and methodsWe conducted focus groups with patient and researcher participants recruited from three academic health centers via snowball sampling. Discussions focused on perspectives on the use of electronic health record (EHR) data for research. Themes were identified through consensus coding, starting from an exploratory framework.ResultsWe held two focus groups with patients (n = 12 patients) and two with researchers (n = 8 researchers). We identified two patient themes (1-2), one theme common to patients and researchers (3), and two researcher themes (4-5). Themes included (1) motivations for sharing EHR data, (2) perspectives on the importance of data-sharing transparency, (3) individual control of personal EHR data sharing, (4) how EHR data benefits research, and (5) challenges researchers face using EHR data.DiscussionPatients expressed a tension between the benefits of their data being used in studies to benefit themselves/others and avoiding risk by limiting data access. Patients resolved this tension by acknowledging they would often share their data but wanted greater transparency on its use. Researchers expressed concern about incorporating bias into datasets if patients opted out.ConclusionsA research consent and data-sharing platform must consider two competing goals: empowering patients to have more control over their data and maintaining the integrity of secondary data sources. Health systems and researchers should increase trust-building efforts with patients to engender trust in data access and use

Massage for Pain: An Evidence Map.

Objectives: Massage therapy has been proposed for painful conditions, but it can be difficult to understand the breadth and depth of evidence, as various painful conditions may respond differently to massage. The authors conducted an evidence mapping process and generated an "evidence map" to visually depict the distribution of evidence available for massage and various pain indications to identify gaps in evidence and to inform future research priorities. Design: The authors searched PubMed, Embase, and Cochrane for systematic reviews reporting pain outcomes for massage therapy. The authors assessed the quality of each review using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) criteria. The authors used a bubble plot to depict the number of included articles, pain indication, effect of massage for pain, and strength of findings for each included systematic review. Results: The authors identified 49 systematic reviews, of which 32 were considered high quality. Types of pain frequently included in systematic reviews were cancer pain, low back pain, and neck pain. High quality reviews concluded that there was low strength of evidence of potential benefits of massage for labor, shoulder, neck, low back, cancer, arthritis, postoperative, delayed onset muscle soreness, and musculoskeletal pain. Reported attributes of massage interventions include style of massage, provider, co-interventions, duration, and comparators, with 14 high-quality reviews reporting all these attributes in their review. Conclusion: Prior reviews have conclusions of low strength of evidence because few primary studies of large samples with rigorous methods had been conducted, leaving evidence gaps about specific massage type for specific pain. Primary studies often do not provide adequate details of massage therapy provided, limiting the extent to which reviews are able to draw conclusions about characteristics such as provider type